OOlUWBiA  UBRARIES  OFFSITE 

HEALTH  SClFNCtS  STANDARD 


THE 


GERY    OF    THE    HATfD 


BEING   TIIK 


CAEPENTEIl  LECTURESHIP   ADDEESS 


THE   NEW  YOUK   xVCAJDEMY   UF  MEDICINE 


BY 


EGBERT  ABBE,   M.  D. 


OF  IfBW  TOBK 


NOVEMBER  TWENTIETH 
1893 


PUBLISHED   BY   THE   ACADEMY 


RD-^51 


intljeCttpofBfttigork 
CoUege  of  ^fipfiiciang  anb  ^urgeong 

iCibrarp 


THE 


SURGERY    OF    THE    HAND 


BEINO    THE 


CARPENTER  LECTURESHIP   ADDRESS 


TlIE  NEW  YORK  ACADEMY  OF  MEDICINE 


BY 


ROBERT  ABBE,  M.  D. 


OP  NEW  YORK 


NOVEMBER  TWENTIETH 
1893 


PUBLISHED   BY   THE   ACADEMY 


fill 


^^  I  give  and  bequeath  Jive  thousand  dollars  to  The  New 
York  Academy  of  Medicine,  with  which  to  found  a  lecture- 
ship to  he  known  as  The  Carpenter  Lectureship,  to  he  paid  to 
the  trustees  of  The  New  York  Academy  of  Medicine,  to  expend 
the  interest  thereon  annually  for  one  medical  lecture.''^ 
[Extract  from  the  will  of  Wesley  M.  Carpenter,  M.  D.] 


(THE  SURGERY  OF   THE   HAND.* 

BY 

ROBERT   ABBE,   M.  D. 

MY  interest  in  the  surgery  of  the  hand  was  first  stimu- 
lated in  1875,  when,  in  assisting  Dr.  Weir  in  a  re- 
section of  the  wrist,  I  read  Liston's  enthusiastic  and  scien- 
tific article  upon  that  subject,  in  which  he  spoke  of  the 
marvelous  mechanical  perfection  of  this  particular  joint. 

No  one  can  contemplate  the  perfect  hand  without  won- 
derment and  admiration,  but,  like  the  use  of  our  eyes  and 
ears,  we  think  little  about  it  unless  its  use  is  impaired. 

Many  of  the  surgical  troubles  that  occur  to  the  hand — 
fractures,  sprains,  etc. — have  their  counterpart  elsewhere  in 
the  body,  and  we  shall  not  consider  these  this  evening. 
Nevertheless,  there  is  great  need  of  wider  knowledge  by 
general  practitioners  of  the  importance  and  gravity  of  such 
common  troubles  as  poisoned  cuts  and  pin  pricks  of  the 
thumb  and  little  finger,  the  suppurative  inflammation  from 
which  spreads  along  the  tendon  sheaths  to  the  common 
bursa  of  all  the  flexor  tendons  above  and  below  the  wrist. 
This  causes  permanent  loss  of  usefulness  of  more  hands 
than  are  destroyed  by  all  other  causes  together.  A  bad  re- 
sult can  only  be  prevented  by  quick  use  of  the  knife  and 
antiseptics. 

Of  very  great  interest  among  hand  troubles,  of  which  I 
find  a  widespread  ignorance  among  physicians,  is  one  which 
has  attracted  my  attention  specially  during  the  last  twelve 
or  fifteen  years,  and  which  is  illustrated  by  some  of  the 

*  The  Wesley  M.  Carpenter  lecture,  delivered  before  the  New  York 
Academy  of  Medicine,  November  20,  1893. 


4  CARPENTER   LECTURESHIP. 

charts  here  displayed — namely,  Dupuytren's  contraction  of 
the  palmar  fascia. 

The  general  surgical  aspect  of  the  malady  has  received 
most  careful  consideration  by  Mr.  William  Adams,  whose 
very  large  experience  in  this  particular  disease  has  ren- 
dered him  the  first  authority  upon  the  subject,  and  it  is 
needless  for  me  to  more  than  refer  to  the  second  edition  of 
his  valuable  work,  issued  last  year,  for  most  of  the  essen- 
tial points  upon  it.  There  are  some  points,  however,  that 
have  come  within  the  scope  of  my  experience  on  which  my 
judgment  differs  somewhat  from  his,  and  to  these  I  will 
direct  especial  attention. 

In  two  previous  articles  written  by  me  upon  this  sub- 
ject, first  in  1884  (see  the  New  YorTc  Medical  Journal, 
April  19th  and  26th,  and  later  in  the  Medical  Record, 
March  3,  1888),  I  proposed  a  theory  of  its  causation  which 
was  entirely  at  variance  with  the  gouty  theory  generally 
accepted  and  since  reiterated  by  Mr.  Adams. 

Reasoning  from  numerous  cases  of  the  neuroses  and 
neuralgias  which  the  patients  with  Dupuytren's  contraction 
were  often  subject  to,  I  satisfied  my  own  mind,  at  least, 
that  there  was  a  strong  probability  that  traumatism  of  the 
nerve  ends  in  the  palm,  reflected  to  the  central  nervous  sys- 
tem and  thence  to  the  opposite  hand,  would  perfectly  ac- 
count for  the  course  of  events  as  seen  in  this  class  of 
cases. 

Mr.  Adams  and  Dr.  Keen,  of  Philadelphia,  have  both 
lingered  over  the  theory  of  its  gouty  origin,  strongly  im- 
pressed by  certain  phases  of  rheumatic  development  in  the 
affected  hands,  and  by  the  occasional  hereditary  tendency 
of  the  disease. 

My  own  experience,  based  at  that  time  upon  about 
twenty-five  private  cases  and  fifteen  additional  public  hos- 
pital cases,  led  me  to  discard  the  gouty  theory  because  of 
the  almost  universal  absence  of  gouty  inheritance  of  the 
patients  who  came  under  my  observation.  It  was  not  rare 
to  find  a  history  of  rheumatism  in  the  families  of  the  pa- 
tients, but  extremely  rare  to  find  a  case  of  typical  gout. 

In  both  my  papers  I  detailed  many  cases  of  striking 
neuralgias  and  neuroses  incident  to  the  course  of  the  con- 
tracted fingers.    It  is  curious  to  me  that  Mr.  Adams  is  able 


ABBE:    SURGKUY    OF    TIIK    UAXD. 


to  say  that  in  the  course  of  his  experience  in  Eng;Iand  he 
has  never  met  with  any  such  cases  of  painful  neuralgias 
and  neurotic  affections   extendins:   to   the   shoulders  and 


spine.  lie  naively  remarks  that  while  I  have  "  asserted 
that  in  English  society  gout  is  an  almost  universal  legacy, 
and  in  America  typical  gout  comparatively  rare,  but  rheu- 
matism more  common,"  he  "  can  not  help  thinking  that 
distressingly  painful  neuralgias  and  various  neurotic  affec- 


Fio.  2. 

tions  are  more  common  in  America  than  in  England."  My 
subsequent  experience,  based  on  an  additional  twenty-live 
cases  in  private  practice  during  the  last  four  years,  into  the 
histories  of  which  I  have  been  able  to  search,  leads  me  fur- 
ther away  than  ever  from  the  presumption  of  gouty  origin. 


6  CARPELS TER   LECTURESHIP. 

A  few  striking  cases  of  neuralgias  have  occurred  among 
these,  but  none  so  pronounced  as  several  that  are  quoted  in 
my  first  two  papers.  Several  cases  in  my  experience  have 
resulted  from  distinct  traumatism  and  scars. 

I  shall  briefly  recount  a  few  typical  cases  to  illustrate 
my  position,  and  I  shall  be  greatly  surprised  if  the  future 
experience  of  others  having  their  attention  called  to  these 
associated  symptoms  will  not  also  reveal  many  that  have 
been  overlooked  by  them.  Except  for  the  typical  gouty 
manifestations  in  the  feet  and  hands,  it  is  easy  to  say  gout 
is  the  cause  of  many  clinical  symptoms  and  hard  to  prove 
it  in  these  contracted  finger  cases.  The  trouble  is  certainly 
absolutely  rebellious  to  antarthritic  remedies,  and  does  not 
come  generally  in  gouty  subjects.  There  is  no  exact  analo- 
gy to  this  palmar  contraction  in  gouty  manifestations  else- 
where. Tophi  are  never  seen  in  these  palmar  contractions, 
no  matter  how  long  they  may  have  existed. 

The  theory  of  gout,  so  far  as  I  can  see,  is  purely  an 
assumption.  On  the  other  hand,  the  disease  affects  a  mem- 
ber whose  tissues  are  highly  endowed  with  nerve  ends.  It 
is  associated  with  pure  neuralgias.  Its  neuralgias  are  often 
relieved  as  if  by  magic  by  an  operation  on  the  bands.  It 
prefers  to  attack  the  ring  and  little  fingers,  the  most  subject 
to  bruises. 


Fig.  3. 


"  The  joints  of  these  hands  are  generally  in  a  healthy 
condition,"  says  Mr.  Adams.  I  myself  have  but  once  seen 
a  truly  gouty  knuckle  in  these  patients.  The  fact  that 
many  patients  can  refer  the  contracting  band  to  injury  and 


ABBE:  SUROERY  OF  THE  HAND.         7 

sometimes  show  scars  is  an  argument  in  favor  of  this  prob- 
able causation  in  all  cases — i.  e.,  traumatism.  Such  cases 
as  the  following  are  not  uncommon  : 

Ten  years  ago  a  patient  was  precipitated  down  an  ele- 
vator, hanging  on  the  chain  for  two  stories.  He  did  not 
experience  any  special  bruise,  except  that  the  skin  was 
slightly  cut  on  the  left  hand  and  torn  a  little  on  the  right. 
Three  or  four  years  later  the  ring  tinger  in  each  was  drawn 
down  a  little  in  the  palm,  the  left  soon  touching  it. 

Several  of  my  patients  attributed  their  contractions  to 
the  driving  of  horses ;  others  to  boat-rowing  and  other  in- 
juries.    One  typical  bruise  may  be  illustrated  as  follows : 

Mr.  O.,  aged  fifty-three  years,  a  most  intelligent  observer  of 
his  family  history,  denies  rheumatism  or  goat  on  either  side 
among  bis  ancestors,  and  is  conversant  with  his  family  history 
for  several  generations  back.  Ten  years  before  this  trouble  be- 
gan he  used  the  palm  of  his  right  hand,  on  the  little-finger  side, 
to  knock  up  the  lever  of  a  heavy  safe  door,  and  has  kept  up  the 
practice  ever  siuce.  In  two  or  three  years  the  contraction  be- 
gan in  the  little  finger  of  that  hand,  and  it  has  progressed  ever 
since.  Dull  aching  was  noticed  in  the  morning  at  the  seat  of 
trouble.  Two  years  later  the  knuckles  of  all  his  joints  of  the 
affected  hand  began  to  act  as  if  subject  to  subacute  rheumatism, 
and  two  years  ago  the  left-hand  knuckles  of  the  corresponding 
fingers  became  red,  swollen,  and  showed  some  disposition  to 
ache.  This  phase  of  rheumatism,  as  pointed  out  and  fully  illus- 
trated in  my  first  paper,  is  a  distinct  neurosis.* 

*  Of  other  cases  attributable  to  accidents  I  would  mention  that  of 
Mr.  P.  K.,  who,  climbing  a  ladder,  had  a  spiked  piece  of  frozen  raortar 
clinging  to  a  round  pierce  his  pahn  over  the  ring  finger.  The  callus 
never  went  away  entirely.  Typical  Dupuytren  contraction  ensued. 
After  two  or  three  years  progiessive  weakness  of  the  ulnar  fingers 
ensued,  diminishing  his  grip  and  associated  with  writer's  cramp. 

In  another,  a  civil  engineer  had  a  long  series  of  stakes  to  put  into 
the  ground,  and  pressed  them  hard  with  his  palm.  Next  day  he  had  a 
sore  palm,  and  dates  his  contraction  from  that. 

I  have  seen  but  one  case  where  Dupuytren  contraction  was  second- 
ary to  neuritis. 

A  man  of  thirty-seven  years  had  his  forearm  caught  between  two 
cars,  80  as  to  jam  the  elbow  at  one  end  and  the  palm  at  the  other. 
Subsequently  he  had  pain  of  ulnar  and  progressive  partial  paresis,  with 
atrophy  of  the  thenar  eminence  and  development  of  true  Dupuytren 
contraction  of  the  fascia  over  the  ring  and  little  fingers,  which  I  dis- 
sected out  with  much  relief,  but  ulnar  neuralgia  with  swollen  nerve, 
easily  felt  at  the  elljow,  continued  as  long  as  he  was  under  observation. 


8 


CARPENTER  LECTURESHIP. 


An  interesting  illustration  of  neurosis  was  shown  byMr.  W., 
who  had  a  sharp  band  developed  in  tlie  middle  finger  ten  years 
before.  Some  contraction  had  also  developed  in  the  left  palm 
later.  The  patient  emphasized  a  curious  neurosis  that  had  been 
present  in  the  right  arm  most  of  the  time,  especially  on  awak- 
ening and  for  some  time  afterward — i.e.,  a  sense  of  great  in- 
crease in  size,  as  if  the  shoulder  and  arm  were  distended  to  twice 
their  natural  size,  giving  a  strange  and  unnatural  feeling ;  occa- 
sionally he  has  pain  about  the  left  shoulder.  In  1885  I  oper- 
ated, dissecting  out  the  band  throughout  the  palm.  There  were 
three  purplish  nodular  swellings  along  tbis  cord.  It  was  done 
under  cocaine  and  painless.  The  finger  came  out  perfectly 
straight.  Two  years  and  a  half  later  the  hand  was  absolutely 
free  from  contraction  ;  the  fingers  could  be  even  bent  backward 
a  little;  the  cicatrix  was  soft  and  white;  he  had  had  no  pain 
for  two  years.  The  neurosis  of  his  arm  entirely  disappeared. 
Moreover,  the  left-hand  bands,  that  had  not  been  operated  on, 
became  softened  a  little  and  gave  no  trouble. 

A  second  case  was  of  much  interest.  Dr.  W.,  a  distin- 
guished physician  of  this  city,  with  absolutely  no  inheritance 
of  rheumatism  or  gout,  attributes  his  contractions  to  the  use  of 
the  rough  head  of  a  cane.  His  father  also  had  had  the  same 
trouble.  In  his  right  hand,  for  fourteen  years,  he  had  a  con- 
tracted ring  finger,  bending  down  well  toward  the  palm.  Re- 
cently he  had  suffered  from  brachial  neuralgia  and  deltoid  and 


Fig.  4. 


cervical  pains,  like  lumbago,  on  the  affected  side.  His  left  hand 
began,  seven  years  after  the  right,  at  the  same  point  precisely. 
There  was  a  burning  sensation  in  the  palm,  and  commencing 
neuralgia  of  his  arm.    The  right  hand  showed  bands  running  to 


ARRE:    SrRCF.RV   OF   TIIK    HAND. 


0 


the  little  and  ring  Hngers;  the  left,  baDds,  faintly  outlined,  go- 
ing to  the  same  fingers. 

This  illustrates  the  almost  universal  fact  that  both  hands 
arc  very  rarely  aflfocted  at  the  same  time;  that  one  follows 
the  other  at  an  interval  even  of  years,  and  that  the  corre- 
sponding fingers  on  the  ulnar  or  radial  side — usually  the 
ulnar — take  much  the  same  position  in  both  hands,  as  is 
well  illustrated  in  Kigs.  4  and  o.  These  points  are  an  argu- 
ment in  favor  of  the  reflex  action  of  one  hand  through  a 
corresponding  nerve  to  the  opposite  hand. 

There  was  more  or  loss  swelling  of  the  knuckles  of  both 
hands,  resembling  rlioiimatism.  In  I8S9  I  cut  out  the  band  in 
the  riglit-hand  finger,  and  made  two  transverse  cuts  to  release 
the  little  finger.  Six  months  later  Dr.  W.  came  to  see  about 
having  the  left  liand  cut,  reporting  that  the  operation  on  the 
right  hand  had  been  most  satisfactory ;  that  he  had  since  had 
but  little  pain  in  the  shoulder,  and  could  put  his  arm  forward 
without  inducing  pain.  The  left  hand  had  been  recently  giving 
neunilgia  of  the  ulnar  side  of  the  forearm  and  numbness  of  the 
little  finger.  Two  years  later  he  made  the  following  graphic 
and  convincing  narrative  of  his  pains  which  had  been  present 
at  first : 

1.  Has  had  no  knuckle  swelling  or  suggestion  of  rheumatism. 

2.  There  has  been  no  pain  at  all  in  the  right  hand. 


Fio.  5. 

3.  The  neuralgia  and  pain  in  the  right  cervical  region  have 
not  returned. 

4.  Until  lately  there  has  been  no  pain  whatever  in  the  right 
shoulder. 


10  CARPENTER   LECTURESHIP. 

5.  The  burning  of  the  left  palm  disappeared  after  the  opera- 
tion on  the  right  hand,  and  has  never  returned. 

6.  The  pain  that  was  slight  but  present  in  the  left  arm  be- 
fore two  years  ago,  no  operation  having  been  done  here,  has 
increased  so  as  to  be  unpleasant,  resembling  sciatic  neuralgia, 
not  limited  to  any  muscle,  but  distributed  in  the  back  of  the  ^irm 
and  the  ulnar  side  of  the  forearm.  The  arm  aches  when  raised 
to  the  horizontal,  and  has  an  unnatural  feeling  of  heaviness. 

7.  Altogether,  the  left  has  been  the  bad  arm  this  year,  while 
before  the  operation  on  the  right,  that  one  was  the  chief  seat 
of  trouble. 

I  now  operated  upon  the  left  hand,  and  there  has  since  been 
absolutely  no  return  of  trouble.  The  rigbt  hand  illustrated  how 
well  the  excision  method  of  operation  had  done  on  the  ring 
finger.  The  cicatrix  was  fine  and  free  from  recontraction. 
The  little  finger  on  which  crosscuts  were  employed  recon- 
tracted  somewhat. 

A.  B.  was  a  car  conductor,  whose  left  index  finger  had  drawn 
down  into  the  palm  and  interfered  sei'iously  with  his  work. 
He  attributed  it  to  former  hard  plowing  and  hoeing.  He  had 
neuralgic  rheumatism  across  the  shoulders,  so  persistent  that  he 
got  his  coat  on  with  difficulty.  I  made  five  transverse  cuts  and 
released  the  fingers  perfectly.  Two  months  later  he  reported 
himself  absolutely  well  and  free  from  pain,  having  worked 
since  ten  days  after  the  operation. 

In  1888  I  operated  on  A.  C,  aged  fifty-three  years,  for 
Dupuytren's  contraction,  vehich  he  attributed  to  a  strain  while 
turning  a  stopcock  firmly  some  years  before,  when  he  heard  a 
snap  as  if  something  was  breaking  in  his  palm.  The  palm 
puffed  up,  and  then  the  swelling  slowly  disappeared,  the  palmar 
contraction  following  fifteen  months  afterward.  The  left  showed 
a  knot  of  contraction  in  identically  the  same  place  as  the  oppo 
site.  Pain  had  commenced  eight  months  before  I  saw  hira — a 
deep-seated  neuralgic  pain  which  made  him  think  he  had  rheu- 
matism.    After  the  operation  his  pain  disappeared. 

Rerjardiwj  Methods  of  Operation.  —  Following  Mr. 
Adams's  urgent  advice,  the  tendency  has  been  to  resort  to 
the  subcutaneous  division  of  the  bands  at  several  points  in 
the  palm.  This  method  Avas  uniform!}^  resorted  to  by  me 
in  the  early  years  of  my  experience.  Finding  many  recon- 
tractions,  and  believing  that  the  absolute  safety  of  good 
surgical  work  enabled  one  to  cut  out  and  get  permanently 
rid  of  the  offending  band  of  diseased  fascia,  I  have  during 
the  last  few  years  resorted  in  most  cases  to  excision.     The 


AUHE:    Sl'KlJKUY    (if    TIIK    HANK.  \l 

results  have  been  better  than  by  subcutaneous  division  iti 
my  hands.  The  operative  procedure  is  thorough,  safe,  and 
exact.  It  can  be  done  painlessly  and  bloodlessly  with  co- 
caine ana'sthesia  combined  with  Esniarch's  bandage,  and 
leaves  soft  linear  scars. 

The  relative  merits  of  excision  and  subcutaneous  divi- 
sion have  been  illustrated  by  some  of  my  cases  in  whom 
both  methods  were  tried  ;  for  instance  : 

A  lawyer  from  ludiann,  whom  I  saw  in  1K«7,  bad  his  rit,dit 
middle  finger  drawn  down  for  twelve  years,  and  tiie  left  became 
involved  five  years  later.  Tliree  years  beforu  I  saw  him  he 
had  had  a  cross-incision  of  the  right-hand  band  in  the  palm 
which  brought  the  fingers  straight,  and  it  was  useful  for  a  time, 
though  it  afterward  required  another  operation.  This  time 
the  subcutaneous  incisions  were  made  by  an  able  surgeon.  It 
soon  began  to  draw  down  again  when  the  splint  was  removed. 
Six  months  later  the  left  hand  was  operated  upon  by  subcuta- 
neous incisions.  Contraction  had  been  progressive  ever  since 
these  wounds  were  healed.  I  operated  by  linear  extirpation  of 
the  right-hand  band,  not  exposing  the  tendon  or  nerves.  On 
the  left  hand  the  cicatricial  and  fascial  contractions  had  matted 
the  tissues  of  the  palms.  I  made  cross  sections  at  seven  points, 
making  lozenge-shaped  cuts  when  the  finger  was  straightened. 
This  left  the  finger  free.  The  result  was  all  that  could  be  de- 
sired in  both  hands  at  the  time.  Three  years  later  the  left 
hand  had  undergone  recontraction  of  the  ring  finger,  which 
had  been  crosscut,  while  the  right,  where  excision  of  the  banp 
had  been  made,  was  straight  and  supple. 

This  proved  incontrovertibly  to  my  mind  the  superior- 
ity of  excision.  I  then  excised  the  band  that  had  reformed 
in  the  left  hand,  which  had  become  more  prominent,  and 
was  able  to  release  the  fingers  perfectly.  Two  years  later 
a  perfect  result  was  shown  from  both  operations.  Five 
years  had  thus  elapsed  without  recontraction  of  the  first 
excised  bands. 

A  tumefied  condition  of  the  fascial  band  often  precedes 
the  contracted  stage,  and  can  be  readily  cut  across  by  open 
incision,  after  which  the  wound  melts  away  invariably, 
though  in  a  year  or  two  the  band  is  apt  to  recontract 
through  the  scar. 

This  dissolving  of  the  tumefied  cord  when  severed  is  as 
if  the  nerve  filaments   being   cut,  the   path  of   irritation   is 


12  CARPENTER  LECTURESHIP. 

broken,  and  tlie   products  of  inflammation  are  quickly  ab- 
sorbed. 

I  now  give  decided  preference  to  tbe  cutting  out  of  con- 
tracted bands,  wbicb,  tbough  a  somewbat  delicate  opera 
tion  to  do,  is  thorough  and  enduring  in  its  results.  No 
where  is  the  use  of  cocaine  more  satisfactory.  Yet  I  have 
found,  as  has  been  observed  also  by  others,  that,  from  some 
yet  unexplained  cause,  cocaine  will  occasionally  yield  very 
slight  anaesthesia.  I  have  seen  this  on  two  or  three  occa- 
sions only.  A  fine  hypodermic  needle  must  be  used,  and  a 
two-per-cent.  solution  of  cocaine.  Not  more  than  ten  or 
twelve  drops  will  be  needed  if  properly  placed  in  the  derma 
at  points  one  third  of  an  inch  apart  along  the  proposed  in- 
cision over  the  band.  There  will  always  be  found  a  layer 
of  fat  between  the  tendon  sheath  and  fascia.  Interrupted 
fine  silk  sutures  should  adapt  the  cut  edges  exactly. 

A  narrow  strip  of  cleansed  gutta  percha  or  protective 
is  laid  along  the  cut  and  small  compresses  of  damp  gauze 
laid  an  inch  deep  over  this.  Over  all  a  square  of  thin 
gutta-percha  tissue  will  keep  the  dressing  damp  and  favor . 
the  drainage  of  the  capillary  oozing  from  the  cut.  A  firm 
bandage  should  be  applied  before  the  Esmarch  bandage  is 
taken  off. 

The  completed  operation  and  dressing  is  done  within 
twenty  minutes,  which  I  have  found  to  be  about  the  limit 
of  time  that  most  patients  can  comfortably  bear  a  snug  Es- 
march bandage. 

The  first  dressing  should  be  changed  in  twenty- four 
hours.  The  second  on  the  fourth  day,  when  stitches  may 
be  removed. 

Contrary  to  the  custom  of  Mr.  Adams,  who  puts  on  a 
straight  splint  at  once,  I  have  found  it  better  to  let  the 
fingers  assume  a  comfortably  correct  position,  under  a 
dressing  without  splint  (which  will  often  induce  pain  by 
overstretching),  and  I  put  on  no  splint  until  a  week  has 
gone  by  and  the  parts  are  healed. 

Although  I  have  records  in  my  private  note  book  of 
fifty  cases  of  Dupuytren  contraction,  representing  about 
that  number  of  operations,  I  have  never  seen  a  case  of  sup- 
puration after  operation,  although  most  of  those  of  the  last 
four  years  have  been  excised. 


AHHK:    SURGERY    OF   TlIK    HAND. 


13 


The  paralytic  and  inHaiiunatory  deformities  of  the  liand 
— so-called  "  m«/«  eu  (jriff  '''' — are  to  he  carefully  dis- 
tini^uished  from  1  )ii{)iivtren  contraction  hefore  operation, 
the  tendons  in  such  cases  heing  contracted  hut  huried  in 
the  flat  palm  and  not  raised  like  the  hands  of  tlie  latter. 

Contractions  sunnfathif/  Dujyiujtreii's. — Twice  I  have 
seen  children  with  the  little  and  ring  fingers  of  each  hand 
drawn  down  to  the  palm,  looking  like  a  Dupuytren's  con- 
traction, but  purely  of  reflex  origin.  One  case,  seen  Ave 
years  ago,  has  lately  bean  reported  by  the  child's  father  as 
almost  entirely  straightened  with  time. 

Another  quite  frequent  deformity  resem])ling  a  Dupuy- 
tren's contraction  is  seen  in  the  little  finger  curved  by 
reason  of  a  congenitally 
sliort  skin  on  its  j)alniar 
side  preventing  its  being- 
straightened  out  as  its 
neighbors.  On  manipula- 
ting it,  one  readily  feels 
that  there  is  no  band  un- 
der the  skin. 

I  have  seen  one  such 
flnger  with  a  double  twist 
giving  it  a  spiral  curve  to- 
ward its  neighbor. 

The  palm  is  occasion- 
ally traversed  by  bands  of 
congenitally  short  skin  un- 
derlaid by  somewliat  limiting  bands — not,  however,  of  pal- 
mar fascia.  This  is  well  illustrated  by  the  annexed  Fig.  6, 
showing  the  hand  of  a  young  lady  whose  piano  playing  was 
limited  by  inability  to  stretch  the  fingers  far  enough.  This 
was  greatly  improved  by  several  subcutaneous  cuts. 

To  completely  remedy  these  defects  is  not  possible,  but 
mucli  may  be  done  toward  that  end  by  crosscuts  of  the 
short  skin,  allowing  the  lozenge-shaped  gaps  to  granulate 
and  be  stretched  later.  This  I  have  done  in  several  cases 
and  acquired  a  soft  scar. 

Neuroses  of  the  Hand. — These  belong  mostly  to  the 
province  of  the  neurologist,  but  some,  being  of  surgical  in- 
terest, may  be  mentioned  : 


Fui.  0. 


14:  CARPENTER   LECTURESHIP. 

An  intelligent  lady  of  forty-five  years  ran  a  threaded  needle, 
head  first,  into  the  middle  of  her  middle  finger  on  its  palmar 
side.  She  experienced  not  much  pain,  but  an  entirely  dispro- 
portionate shock  to  her  nervous  system.  She  was  bewildered 
and  could  not  collect  her  thoughts  for  a  few  minutes.  The 
needle  being  tightly  stuck  in,  she  had  to  use  force  and  pulled  it 
with  her  teeth.  She  observed  a  stringy  fiber  came  with  it, 
which  her  doctor  said  was  a  nerve.  She  walked  home  an  hour 
later,  but  was  overcome  by  bewildered  feelings.  She  lost  her 
memory  and  found  herself  leaning  against  a  house  some  dis- 
tance away. 

Her  nervousness  continued,  and  on  the  second  night  she 
awoke  like  a  mad  person  with  intense  pain  and  a  swollen  finger. 
Suppuration,  erysipelas,  and  pyaemia  followed.  One  night  she 
awoke  with  aphasia  and  left  hemiplegia,  and  did  not  recover 
speech  for  six  weeks. 

When  convalescing  she  had  spasmodic  contraction  of  the 
face,  arms,  and  legs  during  dressing  of  the  hand.  The  healthy 
side  became  hypereesthetic.  It  was  three  months  from  the 
accident  before  she  began  to  walk.  She  still  mixed  her  words, 
and  when  I  saw  her  two  years  later  she  was  in  an  overwrought 
nervous  state  with  a  hand  unfit  for  manual  work.  Memory, 
which  had  always  been  good  before  the  accident,  was  still  ca- 
pricious. For  example,  she  would  forget  in  ten  minutes  all  I 
had  asked  and  said  to  her,  but  a  week  later  it  would  recur 
clearly  to  her.  She  used  wrong  words  and  was  not  at  the  time 
conscious  of  it,  but  in  half  a  minute  realized  she  had  spoken 
falsely. 

When  she  began  to  speak  after  her  sudden  aphasia  she  had 
to  learn  over  again  the  use  of  most  words  and  the  meaning  of 
many.     She  still  mixed  up  words  in  a  sentence. 

Such  is  the  liistoi'V  of  a  striking  case  of  shock  to  the 
central  nervous  system  from  a  slight  nerve  injury  of  the 
hand. 

A  boy  was  brought  to  me  with  the  ring  and  middle  fingers 
of  his  hand  half  closed  into  his  palm.  There  was  no  Dupuy- 
tren  contraction  of  the  fascia.  He  had  been  playing  at  jump- 
ing over  posts  some  years  before  and  bent  down  the  middle 
fingers,  straining  the  knuckles,  which  enlarged,  with  subse- 
•juently  some  rigidity.  Later  the  same  pain  and  stiffness  were 
reflected  to  the  oi)posite  hand  with  occasional  neuralgia  of  the 
shoulders.  He  had  flexor  cramps  when  gripping  a  hammer, 
hoe,  or  rake. 


ABHK:    SUR(;ERY    OF   THE    HAND.  15 

Scvcm'hI  cases  nHrrateil  furtlieroii  represent  also  neuroses 
from  trauinatisins. 

Incidentally  one  may  meet  these  conditions  with  hammer 
palsy,  artisan's  cramp,  or  musician's  cramps,  many  of  wiiicli  I 
have  seen.  Among  them,  one  more  striking  than  another  is  that 
of  a  young  lady,  a  violinist,  who,  being  in  p'.'rfect  liealtli,  was  as- 
signed by  her  teacher  to  play  a  concerto  in  public.  Time  being 
limited,  she  practiced  one  staccato  movement,  which  was  new 
to  her,  for  two  hours  in  succession,  at  the  end  of  which  time 
she  broke  down  completely.  Her  hand  was  useless.  There 
was  complete  muscular  or  nerve  exhaustion.  She  was  unable 
to  write  or  use  her  violin.  Later  she  had  insufficiency  of  the 
eye  muscles,  requiring  prisms,  and  flat  foot,  requiring  her  to 
use  crutches  and  have  a  metal  arch  put  into  her  shoe. 

Seven  years  have  pa.ssed  and  she  has  never  regained  nervous 
force  enough  to  control  her  violin  bow,  or  to  write  more  than 
ten  minutes  without  her  hand  giving  out. 

These  few  illustrative  cases,  chosen  from  many,  suffice 
to  show  the  intimate  relation  between  many  cases  of  hand 
troubles  involving  nerve  ends  and  widespread  disturbances 
of  tlie  system. 

Tumors. — Of  more  special  surgical  interest  are  tumors 
of  the  hand  and  fingers,  of  which  from  many  I  will  narrate 
three  or  four  of  special  interest.  It  is  in  the  hand  that  the 
smallest  tumors  are  often  the  most  troublesome,  because 
conspicuous.  1  have  notes  of  one  little  tumor  as  large  as  a 
small  pea  on  the  end  of  the  thumb  in  a  woman  who  had 
been  prevented  from  sewing  by  it,  owing  to  pain  on  pres- 
sure with  further  pain  in  the  arm.  It  was  in  and  below  the 
deep  layer  of  the  derma,  and  on  being  dissected  out  proved 
to  be  a  purplish-looking  spindle-celled  sarcoma,  denominated 
by  Paget  painful  subcutaneous  sarcoma.  A  second  and 
larger  one  in  another  patient  grew  in  the  center  of  the 
palm. 

I  have  had  four  such  tumors  of  the  hand — two  above 
the  wrist — so  painful  on  being  struck  tliat  they  caused  the 
hand  to  drop  anything  that  the  patient  might  be  carrying. 

One  which  I  dissected  out  ten  years  ago  was  a  typical 
sarcoma,  and  liad  not  recurred  at  the  end  of  eight  years. 
Nor  have  the  others  returned  as  far  as  I  know.  Anotlier 
tumor  at  the  ba.se  of  the  index  was  as  large  as  a  walnut, 


16 


CARPENTER   LECTURESHIP. 


was  soft  enough  to  give  a  striking  sense  of  fluctuation, 
but  proved  to  be  a  pure  fibroma  with  soft  stroma. 

In  the  palm  one  occasionally  sees  small  hernias  of  the 
sheaths  of  the  tendons  buried  in  the  fat  of  the  palm,  little 
cysts  filled  with  transparent  jelly  and  with  very  small  con- 
nection with  the  sheath.  These  are  like  weeping  sinews, 
so  common  on  the  back  of  the  wrist,  but  can  not  be  dissi- 
pated by  a  blow.  I  have  seen  them  disappear  without 
treatment,  but  this  is  so  rare  that  one  should  dissect  them 
out  if  they  give  trouble.  Such  a  one  I  recently  dissected 
out  from  the  fat  of  the  palm  at  the  root  of  the  ring  finger, 
where  it  had  given  annoyance. 

Hyperti'ophy  of  the  Fingers.  —  Hypertrophy  of  the 
knuckles,  very  well  described  in  Tillmann's  Surgery  (Leip- 
sic,  1892),  is  an  epiphysial  hyperostosis,  with  elongation  as 
well  as  broadening  of  the  bones  of  some  of  the  fingers. 
Others  on  the  same  hand  often  remain  normal.  The  draw- 
ings (Fig   V)  are  taken  from  a  photograph  of  a  lad  sent  to 


Fig.  7. 

me  from  a  physician   in   Maine.     The  great  toe  and  the 
second  toe  showed  the  same  extraordinary  enlargement. 

Trigger  Finger. — I  fancy  it  may  be  such  a  growth  that 
causes  the  curious  trouble  denominated  (trigger)  "  snap- 
finger,"  of  which  I  reported  five  cases,  with  illustrations, 
some  years  since  (see  Figs.  8,  9,  10,  and  11,  here  published 
by  permission  of  the  Medical  Mews,  in  which  they  origi- 
nally appeared).  The  patient  closes  all  his  fingers  in  the 
palm,  and  on  opening  them  finds  that  one  will  stay  shut 
and  can  only  be  opened  by  using  the  other  hand  to  effect 
it,  when  it  flies  open  like  a  knifeblade  with  a  snap. 


ABUE:    SUUGEKY   OF   TUE   HAND. 


17 


It  is  said  to  be  due  to  a  tumefied  condition  of  a  point 
of  the  tendon,  jnakiti<,r  a  bulbous  enlargement  that  catches 
under  the  liifainent  at  the  base  of  the  finger.  One  such 
case  is  reported  as  being  capable  of  dissection  and  relief. 
In  my  cases  there  was  no  per- 
ceptible swelling  and  all  re- 
covered after  a  few  months, 
part  of  which  time  they  were 
kept  on   a  little  wood   splrnt 


Fio.  8. 


Fig.  n. 


with  pad  pressure,  Avhich  prevented  friction  and  irritation. 

Of  particular  importance  1  will  mention  two  deformities 
of  the  end  joint  of  the  fingers,  happening  from  slight  acci- 
dent, which  need  the  earliest  surgical  care  and  admit  of 
most  particular  work. 

Drop  Finger. — Two  cases  illustrate  what  I  would  call 
"  drop  finger."  Both  happened  from  apparently  insignifi- 
cant causes : 

In  one,  a  lady  was  taking  off  a  stocking,  and  pushing  it  down 
the  side  of  her  leg  with  the  tips  of  her  fingers,  suddenly  found  the 
end  joint  of  her  ring  finger  liad  given  vvny  and  hung  at  right 
angles  to  the  finger,  powerless.  Witli  her  otiier  hand  she  could 
straighten  it,  but  was  unable  to  support  it.  It  appeared  to  have 
nothing  but  skin  over  the  joint  to  hold  it  up.  The  extensor 
tendon,  where  it  thins  out  disproportionally  to  its  size  above, 


18 


CARPENTER   LECTURESHIP. 


had  torn  away  from  its  delicate  attachment  to  the  base  of  the 
last  joint. 

In  a  fortnight  the  joint  became  red  and  tender;  a  sharp, 
shooting  pain  extended  from  the  knuckle  to  the  wrist,  forearm. 


arm,  shoulder,  and  back  of  the  neck.  It  was  often  severe  enough 
to  make  her  wholly  sick. 

She  volunteered  the  statement  that  a  fortnight  after  the  ac- 
cident the  same  joint  of  the  other  hand  pained  her  when  using 
it.  This  pain  lingered  six  months  after,  when  I  first  saw  her. 
The  injured  hand  was  quite  disabled  on  that  account.  It  was 
tender  if  touched,  ached  if  used,  and  if  struck  by  mishap  it 
"made  her  sick  all  over." 

It  was  now  impossible  to  straighten  it  on  account  of  the 
inflammatory  sealing  up  of  the  torn  capsule.  I  therefore  re- 
sected the  joint  and  made  a  solid,  straight,  and  useful  finger. 
When  it  was  healed  she  was  free  from  pain.  I  have  to-day 
seen  her,  more  than  five  years  since  operation,  and  she  has  not 
since  had  pain  and  uses  the  finger  as  if  it  were  never  hurt. 

The  second  case  in  which  I  operated  was  on  a  prominent 
architect,  whose  ring  finger  dropped  useles<»  at  the  last  joint 
from  the  slight  pressure  of  his  finger  tips  pushing  across  a  paper 
from  off  which  he  was  brushing  some  crumbs. 

I  operated  two  weeks  later,  when  his  physician  found  him- 
self unable  to  keep  the  joint  straight,  even  using  a  splint. 
Through  a  linear  cut  on  the  back  of  the  knuckle  I  sutured  the 


AHHK:    SLliCiEKV    oK    TlIK    11AM). 


10 


torn  end  of  the  tendou  to  the  periosteuiii  of  tlie  base  of  the  last 
joint.     The  result  four  years  after  lias  been  most  admirable. 

Baseball  Finger. — The  reverse  defonnity  to  the  above 
is  now  very  commonly  seen  in  baseball  players.  The  last 
joint  is  violently  dislocated  backward  and  can  not  be  re- 
placed, on  account  of  the  flexor  tendons  wrapping  them- 
selves round  the  head  of  the  proximal  bone  of  the  joint, 
which  also  slij)s  out  through  a  buttonhole  of  the  capsule. 
This  accident  makes  a  permanent  bayo- 
net deformity.  It  is  very  apt  to  be 
compounded  by  laceration  of  the  skin 
at  the   flexure   crease.      In   three  such 


Vv..  11. 


Fio.  12. 


Fio.  13. 


cases  I  have  been  able  to  restore  the  parts  perfectly  through 
incision,  though  in  one  I  had  to  resect  the  head  of  the  bone 
and  make  a  stiff  joint. 

Burn  Scars. — Some  of  the  worst  deformities  of  the 
hand  one  ever  sees  are  produced  b}'  burns.  These  have 
heretofore  been  the  bete  noire  of  the  surgeon.  Now  it  is 
possible,  thanks  to  Professor  Thiersch,  to  restore  many  of 
the  worst  cases  to  usefulness  by  skin  grafting. 

I  will  mention  only  a  few  of  the  bad  cases  I  have  had. 

Two  almost  similar  in  deformity  were  produced  in  girls 
working  in  laundries  where  ironing  mangles  were  used,  the 
upper  cylinder  of  which  is  kept  hot. 

Their  hands,  being  drawn  under  the  roller,  were  burned 


20 


CARPENTER   LECTURESHIP. 


to  the  bone  from  the  knuckles  to  the  wrist,  and  the  result- 
ing slough,  including  tendons,  left  a  scar  which  drew  the 
hand  directly  back  upon  the  wrist. 

Dissecting  out  such  massive  scars,  one  brings  the  fingers 
as  nearly  straight  as  possible  and  makes  Thiersch  grafts 
over  the  parts  exposed.  Two  such  cases  are  illustrated  on 
the  charts. 

A  unique  accident  brought  a  young  man  to  me  with  broad 
ulcerated  surfaces  around  each  wrist,  threatening  hira  with  ul- 
timate loss  of  wrist  action.  He  had  been  cleaniDg  a  pair  of 
gloves  with  benzene  and  had  on  celluloid  cuffs.  The  former  ig- 
nited and  set  fire  to  his  cuffs,  which  burned  like  tinder.  He 
made  frantic  efforts  to  get  Ihem  off,  but  they  were  stiff  and 
only  burned  him  worse  for  handling,  so  that  they  practically 
burned  themselves  off  in  situ. 

I  planted  Thiersch  grafts  on  both  wrists  with  the  happiest 
result.     All  scars  were  perfectly  supple  six  months  afterward. 

Indeed,  I  may  say  that  these  grafts  do  not  show  the 
contracting  tendency  that  the  scar  tissue  does,  and  are 
adapted  to  burn  cicatrices  perfectly.     Indeed,  I  have  cov- 


FiG.  14. 


Fio.  15. 


ered  the  entire  arm  from  the  back  of  the  hand  to  above 
the  elbow  with  them,  and  had  fine  supple  skin  three  years 
after. 

Webbed  Fingers. —  There   is   one  finger  deformity  to 
which  this  method,  therefore,  specially   applies — namely, 


AlJIiK:    SURGERY    OF    TUP:    HANI).  21 

webbed  fingers.  All  that  is  needful  is  to  split  the  web  and 
dissect  out  any  tough  part  well  down  between  the  fingers, 
then  put  a  long  strip  of  Thiersch  graft  up  one  side  and 
down  the  other,  retaining  it  by  gutta-percha  tissue  at  the 
flexion. 

Such  a  case  of  all  the  fingers  I  put  up  in  a  permanent 
dressing  at  the  time  of  operation  and  removed  at  three 
weeks,  to  find  the  parts  perfectly  healed. 

Conservative  Surgery. — I  will  not  weary  you  with  enu- 
merating further  the  many  hand  troubles  which  always 
elicit  the  surgeon's  pity  as  well  as  skill,  but  will  venture 
afield  into  a  novel  inquiry  that  has  occupied  some  of  my 
thoughts  of  late. 

Last  spring  a  well-to-do  man  from  the  West  was  sent  to  me 
with  both  hands  gone  above  the  wrists.  A  dynamite  cartridge, 
with  which  he  had  been  expecting  to  do  some  fishing  by  a 
method  of  which  the  law  takes  cognizance  in  some  States,  had 
exploded  in  his  hands  and  amputation  had  been  required. 
With  Western  energy  he  had  come  East  to  see  if  there  was  not 
some  one  who  could  graft  a  new  hand  upon  Lis  arm.  He  said 
he  was  sure  he  could  persuade  the  Territorial  Governor  to  re- 
lease a  convict  who  would  sacrifice  a  hand  for  remuneration, 
which  he  himself  was  ready  to  pay.  I  could  but  smile  at  the 
Munchausen  tale  such  a  deed  would  make,  and  took  his  address, 
promising,  if  ever  it  became  possible,  I  would  communicate  with 
him. 

Not  long  after  a  man  came  to  me  from  New  Jersey  who 
had  had  a  buzz  saw  plow  through  his  hand  from  the  back, 
severing  all  the  fingers  and  the  thuml>  through  their  metacarpal 
knuckles,  cutting  obliquely  toward  the  wrist,  and  leaving  the 
hand  hanging  by  the  skin  at  the  line  of  the  palmar  arch.  Every 
tendon — both  extensors  and  flexors,  except  the  flexor  of  the 
thumb — was  cut  across. 

It  seemed  inevitable  the  parts  must  be  sacrificed,  but  I  de- 
cided to  see  how  much  could  be  done,  and  spent  three  hours 
and  a  half  trimming  the  torn  tendons  and  muscles,  resecting 
the  disrupted  joints,  and  suturing  the  whole.  1  can  hardly 
believe  that  the  skin  and  some  soft  parts  alone  nourished  the 
fingers,  but  that  one  or  more  of  the  digital  arteries  were  prob- 
ably spared,  though  I  did  not  discover  them. 

The  little  finger  was  the  only  one  that  became  gangrenous, 
the  thumb  and  three  fingers  showing  good  vitality. 

I  saw  the  man  a  few  days  since  after  six  months.  He  now 
uses  his  hand  for  all  work,  and  has  a  little  flexion  of  the  fingers 


22  CARPENTER   LECTURESHIP. 

and  slight  independent  liexion  of  the  end  joints.  The  thumb 
grasps  tightly  against  all  the  fingers  and  he  writes  almost  as 
well  as  ever. 

In  view  of  the  fact  that  surgeons  have  replaced  a  finger, 
an  end  of  a  nose,  and  small  parts  of  flesh  under  favorable 
conditions,  I  asked  myself  why  not  a  major  part,  such  as  a 
hand  or  a  leg  ?  Is  it  our  inability  to  nourish  the  part,  or  to 
innervate  it,  or  to  unite  tendons,  muscles,  or  bone  ?  The 
latter  surely  gives  no  trouble.  Tendons  are  sutured  every 
day,  and  under  favorable  circumstances  their  function  is 
restored.  Nerves  are  frequently  sutured  and  functional 
restoration  is  often  recorded. 

Is  it  impossible  to  restore  an  arterial  supply  once  cut 
off  ?  Veins  are  frequently  cut  and  sutured,  and  perform 
perfectly  afterward.     Is  there  no  way  to  restore  an  artery  ? 

The  question  seems  to  narrow  itself  down  to  nourishing 
a  limb  in  order  to  restore  it. 

Experiments. — During  the  summer  I  made  a  few  ex- 
periments at  the  Carnegie  Laboratory,  with  the  assistance 
of  Dr.  Theodore  Dunham,  and  through  the  kindness  of 
Professor  E.  K.  Dunham. 

To  see  whether  a  thin  glass  tube  would  be  tolerated  in 
a  sterilized  state  within  an  artery,  I  made  a  number  of 
half  inch  pieces  to  suit  the  caliber  of  a  dog's  femoral,  con- 
stricted them  very  slightly  to  an  hour  glass  shape,  and 
smoothed  their  ends  by  heat,  so  that  no  surface  roughness 
should  induce  clotting.  Cutting  the  femorals  across,  I  tied 
each  end  over  the  tube  by  a  fine  silk  thread,  and  tied  the 
thread  ends  together.  Primary  union  resulted,  and  the 
dog's  legs  are  as  good  as  ever. 

I  feared,  however,  that  the  artery  might  have  become 
blocked  in  this  case,  and  the  collateral  circulation  had  nour- 
ished the  limb.  I  therefore  cut  one  out  to  see,  and  tied 
the  femoral  above  and  below.  The  tube  was  free  in  a  di- 
lated end  of  the  artery,  and  slow  endarteritis  had  sealed  it 
below.  Whether  this  would  necessarily  occur  I  decided  to 
see  by  putting  a  tube  in  the  aorta,  where  it  seems  as  if  col- 
lateral circulation  could  not  save  the  limbs.  I  chose  a  cat, 
whose  abdomen  I  opened  and  whose  aorta  I  cut  across, 
clamping  lightly  above  and  below.  Into  this  I  tied  an  inch 
of  very  thin  glass  tube  sterilized  by  boiling,  and  filled  with 


AIJIiE:    SURGERY    OF    THE    HAND.  23 

water  just  before  inserting  into  the  lower  end,  so  as  not  to 
have  air  emboli.  The  cat  made  a  perfect  recovery,  and 
after  four  months  I  show  you  him  to-night,  fat  and  strong, 
with  a  glass  tube  in  his  aorta. 

I  afterward  tried  the  same  experiment  on  a  large  sheep, 
whose  aorta  is  thicker-walled  and  larger.  Unfortunately, 
I  clamped  the  aorta  so  tightly  by  a  broad  pedicle  clamp 
that  I  crushed  the  inner  wall,  and  at  autopsy,  two  days 
afterward,  the  site  of  clamping  was  blocked  by  adhesive 
clot. 

Two  days  ago  Dr.  Dunham  and  Dr.  Cushman  repeated 
the  experiment  on  a  large  dog,  and  he  has  thus  far  been 
well. 

Four  mouths  ago  I  added  one  step  more  to  the  experi- 
ments. I  dissected  out  the  brachial  artery  and  vein  near 
the  axilla  of  a  dog's  fore  limb,  and,  holding  these  apart,  am- 
putated the  limb  through  the  shoulder  muscles  and  sawed 
through  the  bone,  leaving  the  limb  attached  only  by  the 
vessels.  I  then  sutured  the  bone  with  a  silver  wire  and  the 
nerves  with  fine  silk.  Each  muscle  I  sutured  by  itself  with 
catgut,  making  a  separate  series  of  continuous  suturing  of 
the  fascia  lata  and  skin. 

The  leg  was  then  enveloped  in  sterilized  dressing,  a  lib- 
eral use  of  iodoform  gauze  being  the  essential  part.  Over 
all,  cotton  and  a  plaster  jacket  were  placed,  leaving  him 
three  legs  to  walk  on.  A  small  drain  of  the  axilla  was 
removed  at  the  first  dressing  and  a  permanent  dressing 
applied,  which  remained  two  months.  The  dog's  leg 
united  perfectly,  and  he  is  here  to  show  how  well  he  can 
use  it. 

Thus  we  see  that,  if  in  an  amputated  limb  an  artery  can 
be  left,  the  limb  will  survive  the  division  of  everything  else. 
And,  further,  it  may  be  asserted  that,  if  an  arterial  supply 
can  be  restored  to  a  completely  amputated  limb,  that  limb 
also  may  be  grafted  back  to  its  original  or  a  corresponding 
stump. 

Up  to  the  present  I  do  not  feel  that  we  have  incontro- 
vertibly  proved  that  arterial  continuity  can  be  restored  by 
a  glass  tube  in  all  cases.  But  it  is  not  impossible  that,  if 
slow  proliferating  endarteritis  shuts  up  the  main  artery  in  a 
few  weeks,   the  anastomosis   through  the  soft  cicatrix  of 


24  CARPENTER   LECTURESHIP. 

vascular  muscle  and  skin  may  be  able,  by  tbe  recuperative 
power  of  Nature,  to  take  up  the  nutrition  and  ultimately 
carry  it  on. 

The  final  experiment  of  the  series  which  I  set  out 
to  make — namely,  the  complete  amputation  of  an  ani- 
mal's limb  and  its  restoration — requires  preparation,  as- 
sistance, and  time,  so  that  I  have  not  been  able  to 
complete  it  within  the  period  preceding  the  time  ap- 
pointed to  read  this  paper.  I  shall  therefore  report  at 
another  date  to  the  Academy  such  facts  as  may  be  further 
developed. 

Some  one  may  ask.  Where  is  the  supply  of  limbs  to 
come  from  should  it  ever  be  possible  to  graft  a  leg  or  an 
arm  ?  I  may  say  that  I  doubt  not  that  a  limb  crushed, 
let  us  say,  at  the  thigh  or  shoulder,  requiring  amputation, 
would  admit  of  Esmarch's  bandage  being  applied  to  expel 
its  blood  and  of  being  used  after  amputation.  It  should 
be  just  as  viable  as  any  limb  which  we  keep  bloodless  for 
hours  under  Esmarch's  bandage,  and  have  no  trouble  with 
when  blood  is  let  into  it.  Why  not  another  man's  blood 
as  well  as  its  owner's  ? 

I  do  not  expect  that  this  vision  of  surgical  possi- 
bilities will  be  realized  soon,  nor  do  T  think  enoughhas 
been  proved  to  warrant  much  hope,  but  I  feel  that  ex- 
periment in  that  direction  will  yield  much  surgical  in- 
struction. 

The  tolerance  of  sterilized  glass  tubes  in  the  larger  ar- 
teries admits  of  further  application  than  has  been  hinted  at 
in  this  paper. 


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